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Volume 11 No. 12
Earn CME
Accepted Papers

Scientific Investigations

Facilitators and Barriers to Noninvasive Ventilation Adherence in Youth with Nocturnal Hypoventilation Secondary to Obesity or Neuromuscular Disease

Jonathan Ennis, MD1; Kristina Rohde, MA, CE2; Jean-Philippe Chaput, PhD3; Annick Buchholz, PhD3; Sherri Lynne Katz, MDCM, FRCPC, MSc2,4,5
1The University of British Columbia, Vancouver, British Columbia, Canada; 2Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; 3Centre for Healthy Active Living, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; 4Division of Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; 5Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada



Many youth struggle with adherence to bilevel noninvasive ventilation (NIV), often shortly after initiation of treatment. Anecdotal evidence suggests youths with comorbid obesity struggle with adherence while youths with comorbid neuromuscular disease demonstrate better adherence rates. The objective of this study was to explore factors relating to bilevel NIV adherence, and to compare these between youths with underlying obesity or neuromuscular disease.


An exploratory qualitative approach was used to examine youth and caregivers' experiences with and perceptions of bilevel NIV. Semi-structured interviews (n = 16) of caregivers and youths were conducted. Youths 12 years and older with nocturnal hypoventilation diagnosed on polysomnography and managed with bilevel NIV, with either concurrent obesity or neuromuscular disease were included. Thematic analysis of interview data was conducted using qualitative analysis software.


Factors associated with positive bilevel NIV adherence included previous encouraging experiences with therapy; subjective symptom improvement; familiarity with medical treatments; understanding of nocturnal hypoventilation and its consequences; family and health-care team support; and early adaptation to treatments. Factors associated with poor bilevel NIV adherence included previous negative experiences with therapy, negative attitude towards therapy; difficulty adapting; perceived lack of support from family or health-care team; fear/embarrassment regarding treatment; caregivers not being health-minded; technical issues; side effects; and a lack of subjective symptom improvement.


The dimensions which most affect adherence to bilevel NIV are those which contribute to youths' conception of feeling “well” or “unwell.” Adherence to treatment may hinge largely on the way in which NIV is initially experienced and framed.


A commentary on this article appears in this issue on page 1355.


Ennis J, Rohde K, Chaput JP, Buchholz A, Katz SL. Facilitators and barriers to noninvasive ventilation adherence in youth with nocturnal hypoventilation secondary to obesity or neuromuscular disease. J Clin Sleep Med 2015;11(12):1409–1416.

Sleep disordered breathing refers to shallow or absent respirations during sleep occurring as a result of airway obstruction (obstructive sleep apnea) or inadequate respiratory effort to support chest movement (nocturnal hypoventilation).1,2 The latter occurs when respiratory muscles are overloaded as is seen in obesity, where respiratory muscles cannot move excess mass around the thorax to effect respiration,3 and in neuromuscular disease, where respiratory muscles are weak.46 Sleep disordered breathing is a known complication of obesity, with a prevalence of 13% to 66% in obese youths711—strikingly higher than the reported prevalence of 1% to 5% in lean youths.1214 Sleep disordered breathing is also a well-known complication of neuromuscular disease, with a prevalence of greater than 40%; more than 10 times that of the general population.15,16 These are the two primary groups we encounter in our clinical practice of sleep disordered breathing. The management of nocturnal hypoventilation alongside obesity and neuromuscular disease management in youths is imperative to avoid morbidity, and in some cases to increase longevity.


Current Knowledge/Study Rationale: Previous studies of factors affecting adherence to positive airway pressure therapy in children and youth have focused on continuous positive airway pressure (CPAP) treatment. There is an absence of literature evaluating factors related to bilevel noninvasive ventilation (NIV) adherence in youth.

Study Impact: This study highlights specific points at which interventions may be of benefit in improving adherence to bilevel NIV therapy in the study population. The findings of this study suggest that initial education with youth and their caregivers explaining the benefits of bilevel NIV in detail and rapid access to trouble-shooting and support early on in treatment could be key elements to an intervention designed to promote adherence.

Noninvasive ventilation (NIV), achieved with bilevel positive airway pressure (bilevel) therapy, is the mainstay of treatment for nocturnal hypoventilation in obese individuals and in patients with neuromuscular disease. Previous studies of factors affecting adherence to positive airway pressure therapy in children and youth have focused on continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea, which is delivered using equipment similar to bilevel therapy but with one constant pressure. One study highlighted that only 33% of youth consistently used treatment in the first 3 months of therapy.17 Other studies have reported a mean nightly usage of only 3.35–4.5 hours.18,19 To our knowledge, there is an absence of literature evaluating factors related to bilevel NIV adherence in youths and specifically comparing factors related to adherence in different clinical populations.

Previous research has shown that CPAP adherence barriers in obese youths include the youth feeling unwell, forgetting or not feeling like using CPAP, not using the machine when away from home, wanting to forget about having sleep disordered breathing, being embarrassed about CPAP, a lack of help with the CPAP machine at night, and higher final treatment pressures.17,18 Pediatric studies have also shown that the length of time a child was prescribed CPAP and consistent early attempts to use it were predictive of long-term adherence.17,18 In adults, barriers to CPAP adherence also include lower socioeconomic status (SES); technical issues; lack of support; and both negative psychological predispositions and effects of the treatment.2025 Factors supporting CPAP usage in the adult population include higher SES; greater burden of social, emotional, and physical problems; positive attitudes toward healthcare and treatment; presence of supports; fear of the consequences of the illness; and experiencing improvement with treatment.22,23,2634 Similar to the pediatric population, an early pattern of adherence to CPAP therapy in adults was a significant predictor of subsequent adherence.24

A recent qualitative study by Prashad et al.35 examined the reasons for adherence to CPAP in adolescents with obstructive sleep apnea syndrome. The authors conducted semi-structured interviews with adolescents and caregivers and determined that significant factors in CPAP therapy adherence included the degree of structure in the home, social reactions, mode of communication within the family, and perceptions of benefits of therapy.

Many youth in our clinical practice are struggling with adherence to bilevel NIV, often shortly after initiation of treatment. This is particularly true in obese youths. Conversely, youths with nocturnal hypoventilation and neuromuscular disease anecdotally tend to have higher rates of adherence to bilevel NIV. A better understanding of factors that promote adherence to bi-level NIV and those that remain barriers is important to improve success of this treatment. Differences between the two groups may provide clues that will inform intervention strategies to promote adherence, which could be developed and evaluated in future studies. The objective of this study was to explore factors relating to adherence to bilevel NIV, and to compare these between youth with underlying obesity and neuromuscular disease.



An exploratory qualitative approach was used to examine youths' and caregivers' experiences with and perceptions of bilevel NIV. This strategy was selected due to the level of detail sought and the lack of previous studies in this population. Such an approach has been used previously in similar studies.35

Participant Selection

The study population included youth aged 12 years and older with nocturnal hypoventilation diagnosed on polysomnography and managed with bilevel NIV, who had either concurrent obesity (body mass index ≥ 95th percentile) or neuromuscular disease (dystrophinopathies, spinal muscular atrophy, or myotonic dystrophy). When available, dyads of primary caregivers and youths were enrolled, with each interviewed individually. In cases of youths with intellectual disabilities that precluded meaningful participation in the interviews, only caregivers were interviewed. Youths and primary caregivers were required to be fluent in either English or French.

Potential participants meeting inclusion criteria were approached by a clinic nurse during a regularly scheduled hospital visit. Research ethics board approval was obtained from the Children's Hospital of Eastern Ontario Research Institute. Informed parental consent and child assent were obtained from all participants.

Data Collection

In keeping with this strategy, we conducted semi-structured telephone interviews with open-ended questions. Interview guides were developed based on adherence factors identified in the existing literature and were reviewed for content validity by two subject matter experts. Elements explored during the semi-structured phone interviews related to the caregivers' and youths' understanding of nocturnal hypoventilation and bilevel NIV, their beliefs and perceptions regarding treatment, technical factors relating to equipment, and family factors such as support at home. These interviews were conducted by phone by a member of the research team and were 30 minutes in duration (see Appendix for interview questions). The interviews were audio recorded and transcribed verbatim for later analysis.

Data Analysis

The de-identified transcripts were entered into NVivo 10 for inductive thematic analysis. As such, data analysis included iterative cycles of reading through interview data, identifying themes in the data, coding those themes, and then delineating these themes and their context.36

Initially, a member of the research team read the interview transcripts to gain an overall sense of the data, noted areas of connections, and reflected on preliminary interpretations, formulating an initial code. The research team then met to discuss the initial impressions of the data, which informed the development of a coding structure. The member of the research team conducting the analysis consulted an experienced qualitative researcher several times in the process in order to discuss the themes and analytical significance. Once a consensus in the coding scheme was developed, the data were filtered through this lens and illustrative quotes were selected. To demonstrate trustworthiness of the findings, the researchers maintained an audit trail of coding decisions, data analysis procedures, and any draft coding structures, as well as engaged in a peer debriefing process throughout.37

The primary analysis compared the adherent and non-adherent study participants. A secondary analysis was performed comparing youth with neuromuscular disease to those with obesity, with particular attention to assessing differences in facilitators and barriers to bilevel NIV use. Finally, the responses of caregivers and youth were compared.

Quantitative Analysis

Self-reported adherence was initially used to classify youths as adherent or non-adherent from information gathered from the interviews. However, In order to verify the qualitative findings, downloads from the NIV machines were obtained to determine youth adherence. Adherence to bilevel NIV was defined as usage for > 4 h per night on > 50% of nights in the preceding month.38 Youths were classified according to this definition into adherent and non-adherent groups. Direct measures of adherence to therapy were downloaded from the individuals' bilevel NIV machines. This was analyzed for hours of usage per night and nights of usage per week. Agreement between measured and reported (caregiver and youth) adherence was evaluated using Cohen's κ.

Data were also extracted from the youths' initial diagnostic polysomnograms, specifically the initial apnea-hypopnea index (AHI), measured as events per hour, as a measure of disease severity. The association between initial AHI and adherence to bilevel NIV was assessed using the Mann-Whitney test to evaluate the effect that disease severity may have on adherence to therapy.


Sample and Demographics

A total of 16 qualitative interviews were conducted. These were composed of 7 youth-caregiver dyads of 4 youths with obesity and 3 youths with neuromuscular disease. Additionally, the caregiver of a child with neuromuscular disease, and the caregiver of another child with obesity participated. Demographic and clinical data trends are presented in Table 1.

Demographic and clinical characteristics of youth.


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Table 1

Demographic and clinical characteristics of youth.

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Sixty-six percent (6/9) of participants subjectively reported adherence to NIV therapy, including 75% (3/4) of youth with neuromuscular disease and 60% (3/5) with obesity. Of the 9 youths who participated, subjective adherence was concordant with measured adherence in all but one case, an individual who did not subjectively report adherence, but whose download indicated adherence. Cohen's κ was 0.73 (95% confidence intervals 0.24–1.0, p < 0.05).

Youths' AHI, a measure of severity of nocturnal hypoventilation, were obtained from their initial diagnostic sleep studies. The AHIs were compared with objective measures of NIV adherence. No statistically significant association was identified between initial severity of illness and adherence (p = 0.242, Mann-Whitney test). Additionally, maximum carbon dioxide (Max CO2—either end-tidal or transcutaneous) can be used as a measure of disease severity. The average Max CO2 value in the neuromuscular population was 51.8 ± 6.2 mm Hg (range 43–57 mm Hg).

Primary Analysis: NIV Adherent vs. Non-Adherent Youth

When the whole study sample was considered, factors associated with bilevel NIV adherence included aspects related to the youths themselves, their caregivers, the healthcare team, and the equipment (Table 2). Youths were more likely to use bilevel NIV if they had a previous positive experience with nocturnal ventilator therapy, had subjective improvement in symptoms of nocturnal hypoventilation, and/or viewed bilevel NIV as similar in quality to other medical treatments. Those who adapted early to bilevel NIV and had little early difficulty with use, were more likely to be adherent. The knowledge and attitudes of the youths and caregivers promoted adherence, particularly an understanding of nocturnal hypoventilation and its consequences (both long-term and short-term) as well as motivation to improve their health.

Comparison of themes between adherent and non-adherent youth/caregiver dyads.


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Table 2

Comparison of themes between adherent and non-adherent youth/caregiver dyads.

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Familiarity with the healthcare system or medical treatments and technologies was also associated with bilevel NIV use. This was the case when youths had either a previous personal experience of poor health outcome, or of another significant health issue in themselves or a family member. Finally, the support of caregivers and the healthcare team promoted adherence. This was noted when caregivers were in charge of ventilator use and maintenance, actively supported it, and were strict with its use.

In contrast, factors associated with poor NIV adherence included aspects related to the youth's and family's knowledge and attitudes about bilevel NIV, the youth's perceptions about bilevel NIV, and technical issues. Specific comments from the interviews are detailed in Table 2. Adherence was likely to be poor if youths and caregivers felt the healthcare team was not supportive or prompt, and if caregivers were not health-minded (i.e., having limited knowledge or understanding regarding illness and treatment). Poor adherence was more likely if care-givers did not provide intensive support and if the youth was primarily in charge of ventilator use and maintenance. Youths were also less likely to adhere to therapy if they felt embarrassed about it, were fearful of it, or had an early attitude that therapy would be ineffective. A previous or early negative experience with therapy, difficulty adapting to therapy early, protracted technical and comfort issues; experiencing side effects of therapy, or a lack of subjective improvement in nocturnal hypoventilation symptoms also contributed to non-adherence.

Subgroup Analysis by Diagnosis

Caregivers and youths with neuromuscular disease who were adherent to treatment endorsed the presence of hypoventilatory symptoms prior to therapy and the improvement of symptoms associated with treatment. There were also important cognitive and emotional similarities within this group. Among all members of this group, the caregiver approached bilevel NIV with a positive attitude— that is, the expectation that bilevel NIV would be useful, and not prohibitively inconvenient. These attitudes appear to correlate with the past experiences of caregivers with bilevel NIV or with other nocturnal respiratory issues either with a loved one or themselves.

Adherent obese youths and their caregivers felt well supported by the healthcare team, and importantly, felt that the response to complaints or early barriers was prompt and effective. Further, each adherent member of the obesity population had either the presence or experience of a significant or ongoing health issue requiring treatments, or the experience of symptom improvement with treatment. An important item identified by caregivers of adherent members of the obesity population was the occurrence of a specific “buy-in”conversation with the youth. A comparison of comments from the neuromuscular and obesity groups is found in Table 3.

Comparison of select themes between youth with neuromuscular disease with their caregivers and youth with obesity with their caregivers.


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Table 3

Comparison of select themes between youth with neuromuscular disease with their caregivers and youth with obesity with their caregivers.

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With respect to the poorly adherent youth, there were numerous shared themes and ideas. However, there were no distinguishing factors of note between poorly adherent youths with obesity or neuromuscular disease.

Subgroup Analysis by Respondent

Youths seem primarily affected by current experiences— the way that they feel at the moment. The most salient factors noted included comfort, symptom relief, side effects, self-consciousness, and empowerment.

In contrast, caregivers do not share these same perspectives. Caregivers are concerned with long-term factors. That is, past experiences, expectations of the treatment, understanding of benefits and consequences, and health attitudes and literacy were identified as important factors to adherence.


To our knowledge, there has been no previous work specifically examining adherence to bilevel NIV, as opposed to CPAP, in the pediatric population. Furthermore, we have distinctly compared neuromuscular and obese populations (the neuromuscular population having anecdotally better adherence) so as to identify facilitators and barriers via this comparison. This juxtaposition is important because different clinical patterns have been observed in the adherence of these two groups; examining the groups side by side was expected to draw out key differences in an adherent population, which may shed light on possible interventions or strategies that could be helpful in non-adherent patients. It was expected that the neuro-muscular population would be qualitatively different from the obese population, in a way which might explain differences in adherence. However, it appears that when considering these populations in terms of barriers and facilitators to adherence, the adherent and non-adherent groups seem more internally similar than do obese or neuromuscular populations.

Similar to the study of adolescent adherence to CPAP by Prashad et al.,35 we found that use is affected by the physical experience of the youth. Adherent youth experienced great symptom improvement, while non-adherent youth were more likely to experience less or no benefit and to be troubled by adverse effects. The caregivers of youths with poor adherence sometimes attributed this to difficulty convincing the youth of treatment benefits. These were cases in which the youth was primarily in charge of use. Also, similar to the study by Prashad et al.,35 youths with poor adherence were found to display some elements of rebellion against authority and challenging limit setting, and the issue of CPAP use was one of contention with caregivers. Additionally, the youths with poor adherence tended to disproportionately report negative experiences with the treatment. These included being distressed by side effects and finding the therapy interfered with sleep more than improving it. The interplay between co-existent behavioral sleep disorders, such as insomnia or poor sleep hygiene, and PAP adherence were not explored in this study, but may have contributed to poor adherence.

Many of the emergent themes support an overarching concept which drives adherence—youths do not like to feel sick. The dimensions which most affect adherence are those which contribute to the youth's conception of feeling “well” or “un-well.” The items which most clearly affect adherence were experience with a past or comorbid illness, the subjective experience of improved hypoventilation symptoms, and the attitudes with which treatment was approached. These items suggest that the adherence to treatment may hinge largely on the way in which NIV is initially experienced and framed by the youths and the caregivers respectively. A person who has experienced illness and engages in treatment may be more predisposed to view medical interventions as a step towards good health and well-being, whereas a person who has never required a medical intervention may see something like an assistive device as a reminder of illness. Furthermore, youth who believe that bilevel NIV will alleviate some of the burden of their illness are more likely to be adherent with therapy.

It was evident from our results that buy-in from the youth and caregivers is critical and may be a possible area of intervention for improving adherence. It was important in the adherent youths with a lower burden of comorbid disease symptoms, often those with obesity rather than neuromuscular disease, that a specific “buy-in”conversation was had involving the youth, caregivers, and the healthcare team. This consisted of educating caregivers and youth regarding nocturnal hypoventilation and bilevel NIV, but also helping them to understand the consequences of nocturnal hypoventilation on long-term health. The parents of youth with poor adherence felt that a connection with the healthcare team, such as this, was lacking. Despite the fact that all participants in this study interacted with the same healthcare team, their very different experiences of this interaction tended to correspond with the degree of adherence and satisfaction with the therapy.

This study has some limitations. The sample studied is relatively small. The themes explored could be further clarified and confirmed with a larger sample. As well, as this is primarily a qualitative study, the analysis is subject to the bias of the member of the research team who conducted the majority of the interviews, and analyzed the majority of the interview transcripts. We limited this bias by comparing theme analysis and coding schemes to those generated by an experienced qualitative researcher and confirmed there was a level of agreement. Future studies will also consider socioeconomic factors and educational level of participants as contributors to adherence to PAP therapy.

In conclusion, the findings of this study suggest that initial education of youth and their caregivers explaining the benefits of bilevel NIV in detail and rapid access to trouble-shooting and support early on in treatment could be key elements to an intervention designed to promote adherence. Future investigations should focus on conducting a larger scale needs assessment of the problem and subsequently designing and evaluating such an intervention.


This was not an industry supported study. The authors have indicated no financial conflicts of interest.



apnea-hypopnea index


continuous positive airway pressure


noninvasive ventilation


socioeconomic status



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  1. Can you tell me about when you started bilevel therapy? Can you tell me about being on bilevel therapy? (prompt: What factors made beginning and staying on bilevel therapy easy or difficult? What factors made you feel well or poorly prepared? Why do you think you are able to consistently use or not use your bilevel therapy now? What makes it easy or difficult? And what may have been lacking when you started and what may be lacking now?)

  2. What were/are your attitudes towards bilevel therapy before beginning and now? (prompt: when you were first told, what was your reaction/impression?) What about having a hypoventilation during sleep? What about your/ your child's general health? (prompt: Were you/are you particularly focussed, concerned, calm, indifferent, anxious?) What about medical treatments/technologies? (prompt: do you/your child have any other medical technologies or treatments in the home?)

  3. What are your/your child's relationships like with the healthcare personnel involved in your/your child's care? What about your/your child's family members? What about your/your child's friends? (prompt: In general and as they pertain to bilevel therapy. Are they supportive and helpful?)

  4. Have you received any support with respect to bilevel therapy? (prompt: How have you been supported or how would you have liked to have been supported, and by whom, before and during bilevel therapy?) (prompts: by friends? By family? By medical staff? Through encouragement? Education? Technical help?)

  5. For parents: What has your role been as it pertains to treatment prior to initiation, and during bilevel therapy?

  6. What are your/your child's symptoms like now compared to before the initiation of treatment? And do you/your child have any new symptoms or side effects? (prompt: headaches, tiredness, difficulty concentrating, irritability, hyperactivity, dry mouth, dry/stuffy nose, skin breakdown, number of awakenings)

  7. Prior to initiating treatment, what was your/your child's energy and activity level like? (prompt: how active were you/was your child and in what kinds of activities did you/your child participate?) And has your/your child's activity or energy level changed since beginning treatment? (prompt: How active are you/your child now, and what kinds of activities do you/your child participate in now?)

  8. Do you/your child have any problems with your bilevel therapy machine? (prompt: This can include the fit of the mask, discomfort, the noise, setting up the machine at night, alarms going off, removing the mask at night, replacing your child's mask at night)

  9. Can you tell me how many hours per night you/your child currently use the bilevel therapy? How many nights per week?

  10. Are there any things you can think of that your treatment team could have done to make beginning or staying on bilevel therapy easier for you/your child?